Ocd a hidden_epidemic

30 years ago…..
 Being diagnosed with
obsessive-compulsive disorder
(OCD) was about the closest
thing the psychiatric world had
to being given a life
sentence…..
 In addition to being seen as
extremely rare, ….prognosis for
those with a diagnosis of OCD
was very poor….,
 …..with no effective truly
pharmacological or
psychological treatments

OCD
 OCD is characterized by intrusive,
troubling thoughts (obsessions), and
repetitive, ritualistic behaviors
(compulsions) which are time
consuming, significantly impair
functioning and/or cause distress
 When an obsession occurs, it almost
always corresponds with a massive
increase in anxiety and distress.
Subsequent compulsions serve to
reduce this associated anxiety/distress.
Lack CW, World J Psychiatry. 2012 Dec
22;2(6):86-90

Prevalence of OCD
 The lifetime prevalence rate of OCD is estimated
at( USA)
 2.3% in adults and
 around 1%-2.3% in children and adolescents
under 18.
 Sub-clinical” cases of OCD (around 5% of the
population)
 Few epidemiological differences across different
countries and even between European and
Asian populations 1
 Notably, 30-50% of patients develop OCD
starting in childhood 2
1. Lack CW , World J Psychiatry. 2012 Dec 22;2(6):86-
2. Brian P. Brennan et al, Biol Psychiatry. 2013 Jan 1;73

OCD in children and adolescents
 Early-onset obsessive-
compulsive disorder (OCD) is
one of the more common
mental illnesses of children
and adolescents, with
prevalence of 1% to 3%.
 Its manifestations often lead to
severe impairment and to
conflict in the family Walitza S et al, Dtsch Arztebl Int. 2011 Mar;108(11

The CSTC circuitry implicated in
OCD
Pittenger C et al, Pharmacol Ther. 2011 Dec;132(3):314

 Wu et al. [16] summarized the prior literature on the
pivotal role of glutamate in corticostriatal-
thalamocortical (CSTC) models of OCD.
 One of the leading OCD models is based on the
balance between direct and indirect pathways within
CSTC circuits.
 According to this theory, reciprocal interaction
between direct (ultimately leads to thalamic
stimulation of the cortex) and indirect (ultimately leads
to thalamic inhibition of the cortex) pathways normally
resulted in a dynamic balance with no one pathway
predominating.
 Hyperactivity of the direct pathway or hypoactivity of
the indirect pathway would disinhibit CSTC circuits
and promote consequent release of hardwired
behaviors (compulsions) and cognitions (obsessions)
that were normally held in check

Pathophysiology of OCD
 As yet Unknown
 Abnormalities in the orbital (OFC),
ventromedial (vmPFC-subgenual cingulate
and medial OFC), and dorsal anterior
cingulate (dACC) cortical-basal ganglia
circuits
 OCD-linked patterns of activity in these PFC
regions are accentuated during provocation
of symptoms
 They can predict treatment response
 They tend to normalize following successful
treatment
Haber SN et al, Neuropsychopharmacology. 2013 Ja

Neurotransmitter alterations in OCD??
 Linkage of OCD risk with polymorphisms in the serotonin
transporter
 Increased serotonin in peripheral blood has been reported in
OCD
 Abnormalities in dopamine neurotransmission in OCD: A
reduction in the dopamine D2 receptor
 Abnormalities in glutamate neurotransmission and
homeostasis, especially in the CSTC circuitry
Pittenger C et al, Pharmacol Ther. 2011 Dec;132(3):314

NeuroCircuitry Abnormalities in OCD
 Changes in vmPFC/OFC/dACC
activity
 Overlap in the circuits
 Dysfunction of the
vmPFC/OFC/dACC network
 PFC regions associated with OCD
pathology
Haber SN et al, Neuropsychopharmacology. 2013 J

Genetic factors and OCD
 Twin studies reveal a higher
concordance of OCD in
 monozygotic twins (80–87%) than in
dizygotic twins (47–50%)
 Genetic factors appear to have a
substantial role in the etiology of early-
onset OCD.
Wu K et al, Pharmacol Biochem Behav. 2012 Feb;100(4):726-3

Glutamate Related Genes implicated in OCD
Several glutamate-related genes have been
associated with OCD risk.
 The glutamate transporter gene Slc1A1
 The Sapap3 gene, is critical to the normal
localization of ionotropic glutamate receptors
 The Grin2B gene may be associated with OCD
transmission
 The Grik2 locus is involved in glutamate
neurotransmission
Pittenger C et al, Pharmacol Ther. 2011 Dec;132(

Disrupted neurotransmission of glutamate
in OCD
 Disrupted neurotransmission of
glutamate within corticalstriatal-
thalamocortical (CSTC) circuitry
 Plays a role in OCD pathogenesis.
 Associations between variants for
SLC1A1
Wu K et al, Pharmacol Biochem Behav. 2012 Feb;1

Proinflammatory cytokines in OCD
 Significant reduction in IL-1β
levels
 Lower plasma IL-6 levels.
 Elevated TNF-α levels in
individuals with comorbid
depression.
Gray SM et al, Curr Psychiatry Rep. 2012 Jun;14(3)

ICD-10 criteria for obsessive-compulsive
disorder (age-independent)*
 For a definite diagnosis,
obsessional symptoms or
compulsive acts, or both, must
be present on most days for at
least 2 successive weeks and
be a source of distress or
interference with activities.

The obsessional symptoms should have the
following characteristics:
 They are acknowledged as originating in the mind of
the patient, and are not imposed by outside persons
or influences.
 At least one obsession or compulsion must be
present which is unsuccessfully resisted.
 Carrying out the obsessive thought or compulsive act
is not in itself pleasurable.
 The thoughts, images, or impulses must be
unpleasantly repetitive

 The patient must suffer from obsessions and/or compulsions,
i.e., thoughts and/or behavioral impulses.
 At least one of these obsessions and/or compulsions must be
resisted.
 The patient does not perceive the manifestations of the disorder
as being pleasurable.
 The obsessions and/or compulsions occur repetitively; the
patient is troubled by them and is markedly impaired by them.

DSM V and OCD changes : Unnecessay but
harmless?
 The APA is considering changing the name of this
category to Anxiety and Obsessive-Compulsive
Spectrum Disorders.
 Obsessive-Compulsive Disorder removed from the
Anxiety Disorders category, and reclassified in its
own category.
 Reason : OCD has a neurological basis. …

DSM V and OCD changes
 The DSM-IV focus was not on the cause of the but
rather on the presenting symptoms that define the
conditions.
 One of the primary defining characteristics of OCD is
anxiety.
 The one common factor - they are highly anxious
about their obsessive and compulsive symptoms.

OCD and DSM-V: Taking the “anxiety” out of
OCD
 Psychiatrists and psychologists debate
whether or not OCD should continue to
be classified as an “anxiety disorder.”
 In some ways, OCD overlaps with other
anxiety-related conditions, such as
 panic disorder
 Phobias
 social anxiety disorder
 generalized anxiety disorder, and
 post-traumatic stress disorder (PTSD).

DSM V and OCD
 The new Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM-5)
 Has a number of changes to obsessive-compulsive and related
disorders, such as hoarding and body dysmorphic disorder.
 A separate chapter for OCD and related disorders
 They are no longer considered “anxiety disorders.
 Disorders in this chapter include
 obsessive-compulsive disorder,
 body dysmorphic disorder and
 trichotillomania (hair-pulling disorder), as well as two new disorders:
 hoarding disorder and excoriation (skin-picking) disorder.

DSM-5
 Obsessive-compulsive and related disorders can
include
 body-focused repetitive behavior disorder and
 obsessional jealousy, or unspecified obsessive-
compulsive and related disorder.
 Body-focused repetitive behavior disorder, is
characterized by recurrent behaviors other than hair
pulling and skin picking (e.g., nail biting, lip biting,
cheek chewing) and repeated attempts to decrease
or stop the behaviors.
 Obsessional jealousy is characterized by
nondelusional preoccupation with a partner’s
perceived infidelity.

Diagnosis with the Y-BOCS
 Define the range and severity of
OCD symptoms
 The Yale-Brown Obsessive
Compulsive Scale (Y-BOCS) is a
good tool
 Complete Mental Status
Examination
 Look for comorbid symptoms and

Imaging studies
 Functional MRI and PET scanning demosntrate
 increase in blood flow and metabolic activity in the
orbitofrontal cortex, limbic structures, caudate, and
thalamus
 with a trend toward right-sided predominance.
 Areas of overactivity have been shown to normalize
following successful treatment with either SSRIs or
CBT.
 These imaging modalities, are of value for research
 They are not indicated for normal workups.

Common obsessions
 Contamination fears
 Worries about harm to self or
others
 The need for symmetry,
exactness and order,
 Religious/moralistic concerns
 Forbidden thoughts (e.g.,
sexual or aggressive), or
 A need to seek reassurance or
confess
Lack CW , World J Psychiatry. 2012 Dec 22;2

Common obsessions
 Safety
 Doubting one's memory or perception
 Scrupulosity (need to do the right
thing, fear of committing a
transgression, often religious)
 Need for order or symmetry
 Unwanted, intrusive sexual/aggressive
thought

Common compulsions
 Cleaning/washing
 Checking
 Counting
 Repeating
 Straightening
 Routinized behaviors
 Confessing
 Praying
 Seeking reassurance
 Touching
 Tapping or rubbing, and
 Avoidance

Common compulsions
 Checking (eg, locks, stove, iron, safety of children)
 Counting/repeating actions a certain number of times
or until it "feels right"
 Arranging objects
 Touching/tapping objects
 Hoarding
 Confessing/seeking reassurance
 List making

Gender differences
 More common in males in pediatric patients.
 There are some differences in comorbidity as well.
 Among men, hoarding symptoms are most often
associated with GAD and tic disorders.
 In women social anxiety, PTSD, body dysmorphic
disorder, nail biting, and skin picking are more often
observed

Cultural influences on symptom expression
 Bali: Heavy emphasis on somatic symptoms and need to know
about members of their social network
 Jews: Emphasis on cleanliness and order
 Muslims : Religious obsessions in Muslim communities
 South America : Aggressive aggressions
 USA : Dirt and contamination worries

OCD in children
 Presentation of OCD symptoms is similar in children
and adults.
 Younger children will not be able to recognize that
their obsessions and compulsions are both
unnecessary
 In young children, compulsions often occur without
the patient being able to report their obsessions
 Adolescents are often able to report multiple
obsessions and compulsions.

OCD in children
 Children and adolescents are also more likely to include family
members in their rituals
 Can be highly demanding of adherence to rituals and rules,
leading to disruptive and oppositional behavior and even
episodes of rage.
 Youth with OCD are generally more impaired than adults
with the same type of symptoms

Comorbid disorders with OCD
 Up to 75% of persons with OCD present with comorbid
disorders.
 In pediatric cases : ADHD, disruptive behavior disorders, major
depression, and other anxiety disorders.
 In adults: Social anxiety, major depression, and alcohol abuse.

Comorbid disorders with OCD
 Primary symmetry/ordering symptoms are often seen
with
 comorbid tics
 bipolar disorder
 obsessive-compulsive personality disorder
 panic disorder, and agoraphobia
 Those with contamination/cleaning symptoms are
more likely to be diagnosed with an eating disorder.
 Those with hoarding cluster symptoms, are likely to
be diagnosed with personality disorders, particularly
Cluster C disorders

OCD and schizophrenia
 The mean OCD prevalence is 13.6%
 The prevalence rate of OCS, defined as any
obsession or compulsion is 30.7%
 The prevalence of OCS and OCD in schizophrenia is
substantial, specifically in more chronic patient
populations
 It is influenced by the method of assessment
Swets M, Schizophr Res. 2013 Dec 19. pii: S0920-9964(13)00

Prevalence estimations of OCS and OCD within
different samples of patients
Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99.

Onset of OCS
 First onset of OCS has been described at different
stages during the course of psychotic illness:
 Before psychosis as independent, co-existing
symptoms or diagnosed OCD.
 Prior to psychotic manifestation as part of the at risk
mental state (ARMS).
 Simultaneously with the first manifestation of
psychosis.
 After the first psychotic episode during the course of
chronic schizophrenia.
 As de novo OCS after initiation of antipsychotic
treatment. Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99.

OCS might manifest at
different time points
during the course of
schizophrenia illness
(A) Pre-existing and
persistent OCS.
(B) Intermittent OCS
during ARMS or later
in the clinical course.
(C) OCS-onset during
ARMS and persistent
course, strongly
associated to the
psychotic symptoms
(schizo-obsessive
concept).
(D) Fluctuating course of
OCS.
(E) Second-onset OCS
during antipsychotic
treatment
Schirmbeck F, Front Pharmacol. 2013 Aug

Identification of obsessive-compulsive symptoms in
schizophrenia.
Insight-criterion Patients suffering from OCD typically fulfill
three symptom characteristics: they attribute
the obsessions, impulsive symptoms and
compulsions to their own thinking, declare
with insight their unreasonableness and
show some degree of resistance against
them. In particular the first two properties
allow a differentiation from hallucinations
and delusions. Ruminations or stereotypic
ego-dystonic cognitions with direct relation
to the contents to psychotic thinking should
not be diagnosed as obsessions.
OCS not solely related to the psychotic
content
Cleaning or checking behavior should be
diagnosed as compulsions only if it is
accompanied by typical obsessions and not,
if the patient currently suffers from delusions
of contamination, intoxication or infection.
Re-evaluation of OCS after remission of
psychotic symptoms
If first manifestation of OCS occurs
simultaneously with the first psychotic
exacerbation, the final decision on a valid
comorbid condition should be postponed
until the remission of psychotic symptoms.
Schirmbeck F, Front Pharmacol. 2013 Aug 9;4

Identification of obsessive-compulsive symptoms in
schizophrenia.
Differentiation from catatonic symptoms Repetitive behavior or stereotypic actions
should carefully be discriminated from catatonic
symptoms most importantly in patients with so-
called “manieristic catatonia.”
Obsessions presented as pseudohallucinations A subgroups of OCS patients, who experience
their obsessions as extremely aversive and
burdening may try to distance themselves by
using expressions such as “voices” or “foreign
thought content”, but in most cases these
phenomena can be characterized as
pseudohallucinations.
SGA-induced OCS Patients without a previous history of OCS
might develop these phenomena during
antipsychotic treatment. This constellation hints
toward the unfavorable effect of second-onset
OCS induced by SGAs.
Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99.

Factors for occurrence of OCS
 The additional occurrence of OCS is associated
with
 high subjective burden of disease
 additional neurocognitive impairment
 poorer social and vocational functioning
 greater service utilization
 high levels of anxiety and depression.
Schirmbeck F,Front Pharmacol. 2013 Aug 9;4

Hypothesis for OCD + Schizophrenia
 Patients with schizophrenia develop OCS as an
attempt to reduce psychotic symptoms ??
 The presence of OCS was proposed to have
protective effects??
 Negative correlations between specific OCS and
the severity of psychotic disorganization in
thinking and behavior, may be due to
compensating mechanisms??
Schirmbeck F,Front Pharmacol. 2013 Aug 9;4

Schizotypic OCD
 Primary OCD-patients present beliefs, which can
be classified on a spectrum between obsessions
and delusions emphasizing the similarities as
being irrational thoughts, the first with insight and
the latter lacking insight.
Schirmbeck F,Front Pharmacol. 2013 Aug

Neurobiological mechanisms in OCD and
schzophrenia
 Pronounced cognitive deficits reflect an
underlying neurobiological risk factor for
schizophrenia patients to develop OCS and
mirror at least partially overlapping
neurobiological mechanisms with OCD
 Serotonergic dysfunctions, alterations in
dopaminergic activity and in glutamatergic
neurotransmission, have also been related to
OCD
Schirmbeck F,Front Pharmacol. 2013 Aug

Impact of OCD on QoL
 Almost all adults and children with OCD report that
their obsessions cause them significant distress
and anxiety
 A pervasive decrease in QOL
 Youth show problematic peer relations, academic
difficulties, sleep problems, and participate in
fewer recreational activities

OCD and bipolar disorder
 Obsessive compulsive features occurring in mania
have been well documented.
 There are very few case reports and studies in India
 This is a complex comorbidity to treat as OCD
requires high doses of SSRIs which precipitates
mania.
 A sound knowledge of etiology and the pathology
operating gives an insight into the comorbidity
Annigeri B, Indian J Psychol Med. 2011 Jan;33(1):83-5

Treatment of OCD and bipolar disorder
 Treatment guidelines may differ as compared with
that of pure cases.
 BPD also responds poorly to mood stabilizing
antipsychotics like olanzapine in the presence of
OCD.
 BPD receives preference with regards to
treatment
Annigeri B, Indian J Psychol Med. 2011 Jan;33(1):83-5

Cognitive-behavioral therapy (CBT)
 The psychological treatment of
choice for OCD
 Effective in both adults and children
 Is backed by numerous clinical trials
 Particularly exposure with response
prevention (EX/RP)

CBT
 It is superior to medications alone, with effect sizes
ranging from 1.16-1.72
 There is a lower relapse rate than in medications (12%
vs 24%-89%)
 Up to 25% of patients will drop out prior to completion
of treatment due to the nature of treatment.
 The course of therapy generally lasts between 12-16
sessions

Differing responses to CBT
 Those with hoarding cluster
symptoms respond less well to
CBT
 Accommodation by family
members in pediatric clients is
predictive of poorer treatment
response as well.
 Intriguingly, group therapy that
uses CBT and EX/RP has been
shown to be equally as effective as
individual therapy
 For persons with mild OCD,
computer-assisted self-treatment
has been shown to be very
effective

Pharmacological treatment
 Treatment is targeted primarily at monoaminergic
neurotransmission, particularly at the serotonin and
dopamine systems.
 The SSRIs are the mainstay of pharmacotherapy
 The SSRIs are of benefit in 50–60% of patients
Pittenger C et al, Pharmacol Ther. 2011 Dec;132

Drug therapy
First-line pharmacologic treatments consist of
 5-HT reuptake inhibitors, such as the SSRIs
(fluoxetine, fluvoxamine, sertraline, paroxetine,
citalopram, escitalopram),
 Clomipramine
 TCA with 5-HT and NE reuptake inhibition.
 Venlafaxine (SNRI).

SSRIs
 SRIs can be successfully supplemented with
adjunctive antipsychotics
 Only a third of patients will show improvements and
there are serious health concerns with their long-term
usage.
22;2(6):86-90

Indian experience with SSRIs in OCD
 The study examined the 5-year course prospectively in 115 OCD
outpatients who were mostly treated with serotonin reuptake
inhibitors (SRIs).
 The outcome of OCD seems to be better than generally
assumed, at least in moderately ill outpatients.
 Regular treatment over extended period may enhance likelihood
of remission.
 Full remission should be the goal of treatment since it is
associated with lesser propensity for relapse.
 Most patients remit in the first 2 years of treatment; therefore,
early detection and intervention may improve the outcome.
Cherian AV et al, J Affect Disord. 2014 Jan;152-
154:387-94

Clinical Pearls
 Adding ERP to SRIs was superior to both
risperidone and pill placebo.
 Patients with OCD receiving SRIs who continue
to have clinically significant symptoms should be
offered ERP before antipsychotics given its
superior efficacy and less negative adverse effect
profile.
Simpson HB JAMA Psychiatry. 2013 Nov;70(11):1190

Clinical Pearls
 Augmenting SRIs with exposure and ritual
prevention versus stress management training
leads to better outcome after acute treatment and
24 weeks later
 The response in combination group was
significantly higher starting from 9th week,
continuing up to 13th week. Mean symptom
reduction and mean percentage reduction of
symptoms were also higher in the case of
combination group.
Foa EB, J Clin Psychiatry. 2013 May;74(5):464-9
Giasuddin NA, Pak J Pharm Sci. 2013 Jan;26(1):95-8

Clinical Pearls
 About one-third of SRI-resistant OCD patients
benefited from an augmentation strategy with
antipsychotics.
 Based on the favourable risk:benefit ratio,
risperidone can be considered as the agent of
first choice and should be preferred to quetiapine
and olanzapine.
Dold M, Int J Neuropsychopharmacol. 2013 Apr;16(3):5

Sertraline for non responders of OCD
 Greater symptom improvement was seen in the
high-dose sertraline group compared to the 200-
mg/day dose group during continuation treatment.
 Both dosages have similar safety profiles.
 Administration of higher than labeled doses of
selective serotonin reuptake inhibitors may be a
treatment option for certain OCD patients who fail
to respond to standard acute treatment
Ninan PT, J Clin Psychiatry. 2006 Jan;67(1):15

Fluvoxamine Vs Clomipramine in OCD
67

Presentation Title
Date
68
 Study objective: To directly compare the efficacy and safety of
fluvoxamine and clomipramine in patients with OCD
 Study Design: Double-blind, randomised, multicentre study
 Patient population: 227 patients with a primary diagnosis of OCD
 Evaluation parameters:
 Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
 National Institute of Mental Health Obsessive-Compulsive (NIMH-OC)
scale
 Global Improvement item of the Clinical Global Impression (CGI) scale
Mundo E. Hum Psychopharmacol. 2001 Aug;16(6):461-468.

69
Fluvoxamine and
clomipramine were
equally effective, both
resulting in clinically
significant
improvement

70
Fluvoxamine and
clomipramine were
equally effective on
secondary endpoints
variable

71
Fluvoxamine was
better tolerated than
clomipramine
The overall incidence
of premature
withdrawal due to
adverse events was
twice as high as with
clomipramine than
with fluvoxamine
(16% Vs 8%)

Cognitive therapy versus fluvoxamine as a second-
step treatment in obsessive-compulsive disorder
nonresponsive to first-step behavior therapy
 OCD patients who are nonresponsive to ERP
(exposure in vivo with response prevention) may
benefit more from a switch to treatment with an
antidepressant instead of switching to CT
 In clinical practice, it may be important to motivate
this subgroup of patients to undergo
psychopharmacological treatment, as this may
improve their outcome considerably
van Balkom AJ, Psychother Psychosom. 2012;81(6):366-

Weight gain with SSRIs
 Clomipramine,, citalopram, fluoxetine, fluvoxamine,
paroxetine, or sertraline
 At the end of the 2.5-years patients had gained a
mean of 2.5% of their body weight with respect to
baseline (1.58 kg)
 Higher proportion of clomipramine-treated patients
(34.8%) gained > or = 7% in weight as compared with
sertraline and fluoxetine
 Sertraline and fluoxetine had the lowest percentage
of patients with a significant weight gain (4.5% and
8.7%, respectively),Maina G, J Clin Psychiatry. 2004 Oct;65(10):1365-71.

Clinical Pearls : Treatment predictors for
fluvoxamine
 Pre-treatment activation in the
 right cerebellum (Z-score=5.10, x,y,z=22,-84,-
18) and
 the left STG (Z-score=4.95, x,y,z=-62,-22,0)
was positively correlated with the improvement
in the Y-BOCS score.
 Pre-treatment activation in the right
cerebellum and in the left STG predict
subsequent reduction in OCD symptom
severity.
 There is every possibility that fMRI can be
used as a tool to predict treatment response.
Sanematsu H et al, J Psychiatr Res. 2010 Mar;44(4):193-20

Major sites of action of glutamate-
modulating drugs

Differing responses
 The presence of tics appears to decrease selective
SRI effects in children, but it is unclear if it has the
same effect in adults.
 Another known difference is that patients who have
OCD with comorbid tics respond better to neuroleptic
drugs than those who have OCD without tics
22;2(6):86-90

Clinical Pearls
 Unlike in the case of major depression, complete
or near-complete remission of OCD symptoms is
rare with only serotonergic antidepressant
treatment.
 More typically, perhaps half of patients may
experience symptom reductions of 30-50%, with
many other patients failing to achieve even this
degree of relief.
 Doses above those needed for treatment of
depression may be more effective for some
patients.
 A therapeutic dose for 6-10 weeks may be
required to observe a clinical response.
 Response tends to be slow and continues for at
least 12 weeks

Clinical Pearls
 For reasons that remain unclear,
higher doses than those used
for depression are often required
for OCD
 In disease refractory to these
agents, pharmacological
augmentation with neuroleptic
drugs, which antagonize the D2
dopamine receptor, can be
efficacious

Clinical Pearls
Role of life events in obsessive
compulsive disorder.
 Life events are significantly more
frequent in OCD patients
 The severity of OC symptoms is
directly proportional to the number of
stressful life events experienced in the
last six months prior to onset.
Sarkhel S et al, Isr J Psychiatry Relat Sci. 2011;48(3):182-5.

Alternative agents
 Use of specific glutamatergic agents (eg, memantine,
N -acetylcysteine, riluzole, topiramate, glycine)
Sarkhel S et al, Isr J Psychiatry Relat Sci.
2011;48(3):182-5.

ERP treatment
 ERP is now usually administered as part of a broader program of
CBT specifically designed for OCD.
 After making the patient aware of his or her irrational thoughts,
the therapist works to have the patient counter them with more
rational thoughts and do cost/benefit analyses regarding
performing his or her rituals.

Treatment resistance strategies
 Strategies should always include an assessment of
 complicating diagnoses
 medication compliance
 drug dose, and
 duration of therapy.
 Comorbid diagnosis such as depression or panic
disorder, can interfere with clinical recovery, and
identification may guide the choice of interventions.
William M Greenberg, Obsessive-Compulsive Disorder Treatment &
Management.www.medscape.com

 Interventions for patients with treatment resistance
include
 Change or increase in medication
 More intensive CBT
 Other interventions, which have not received an
FDA indication for OCD include the following:
 Addition of an NE reuptake inhibitor, such as
desipramine, to an SSRI, or a trial of venlafaxine
 Addition of a typical or atypical antipsychotic,
especially in patients with a history of tics

 Interventions for patients with treatment resistance include
 Augmentation with buspirone
 Addition of inositol
 Sole or augmented use of selected glutamatergic agents
 Deep brain stimulation or cingulotomy neurosurgery or severe
and intractable cases
 Some clinicians feel that individuals with comorbid Tourette
disorder or with hoarding as their principal OCD symptom may
be more likely to be treatment resistant, although there is
significant variation in treatment response, regardless of the
particular presenting symptomatology.

Low-frequency rTMS over the SMA for
treatment-refractory patients of OCD
 Novel treatment strategies like
repetitive transcranial magnetic
stimulation (rTMS) have been
proposed for OCD refractory to
standard treatments
 Low-frequency rTMS over the
SMA appears a promising
treatment strategy as an add-on
treatment in treatment-refractory
patients of OCD.
Kumar N et al,Indian J Psychiatry. 2011 Oct;5

Neurosurgical treatment of OCD
 Neurosurgical treatment of OCD is reserved for
patients with severe and refractory symptoms.
 The most common small series use a specific small
lesion (eg, cingulotomy) or deep brain stimulation.
 Current clinical trials are also exploring the application
of transcranial magnetic stimulation (TMS), a
noninvasive treatment, for OCD.

Neurosurgical treatment of OCD
 Stereotactic placement of bilateral lesions in the anterior
cingulate cortex: 28% response rate, with an additional 17%
showing a partial response.
 A deep brain stimulation technique consists of implanting a
device to electrically stimulate the subthalamic nucleus

FUTURE DIRECTIONS FOR RESEARCH
 Treatment dissemination, particularly for CBT and EX/RP,
remains an issue
 Steps can and should be undertaken to improve
dissemination of CBT
 Dissemination of both the safety and effectiveness of
exposure-based therapies to both the general public and
mental health clinicians
 More research on how certain comorbidity patterns impact
treatment

Study further … New Promising approaches
 Targeting the extinction learning core to EX/RP with
d-cycloserine , a partial agonist at the NMDA
receptor in the amygdala
 Novel combinations of pre-existing treatments

End Note
 There is truly not a better time in history to have
OCD than the present,….
 …. given the multiple effective pharmacological
agents, psychological therapy, and ….an ever-
increasing understanding of the disorder itself.
 This is not, however, the time to sit back and pat
our collective backs in triumph.

Ocd a hidden_epidemic

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